Wellness Form Step 1 of 6 16% WELLNESS QUESTIONNAIREPatient Name:Patient Date of Birth: Date Format: MM slash DD slash YYYY Today's Date Date Format: MM slash DD slash YYYY Last Four of SS No.:Patient Email ADL ASSESSMENT1. Can You Dress Yourself?YesNo2. Can You Feed Yourself?YesNo3. Do You Need Assistance Going To The Restroom?YesNo4. Do You Need Assistance With Bathing?YesNo5. Do You Do Your Own Shopping?YesNo6. Do You Drive?YesNo7. Do You Do Your Own Cooking?YesNo8. Do You Do Your Own Laundry?YesNo9. Do You Handle Your Own Finances?YesNo10. Do You Take Care Of Your Own Medications?YesNo11. Can You Climb 10 Steps Unassisted?YesNo12. Do You Consider Yourself Overweight?YesNo13. Do You Eat Fruits And Vegetables?YesNo14. How Many Days A Week Do You Exercise?15. How Many Hours Of Sleep Do You Get At Night?16. Is There Anything We Can Do To Help You Be Healthier?FALL RISK ASSESSMENT1. Have You Fallen In The Past 3 Months?YesNo2. Do You Feel Weak Or Unsteady On Your Feet?YesNo3. Are You Often Forgetful?YesNo4. Do You Use One Of The Following? Cane Walker Wheelchair None BEHAVIOR ASSESSMENT1. Do You Use A Hearing Aid?YesNo2. Do You Have False Teeth?YesNo3. Do You See A Dentist Yearly?YesNo4. Do You Wear A Seat Belt?AlwaysSometimesNever5. Do You Have Smoke Detectors?YesNo6. Do You Change The Batteries In Your Smoke Detectors Yearly?YesNoALCOHOL/DRUG ABUSE OR DEPENDENCE1. Do You Drink Alcohol?YesNo1.2. How Much?DailyWeeklyMonthly2. Do You Use Recreational Drugs?YesNo3. Have You Ever Felt You Should Cut Down On Your Drinking Or Drug Use?YesNo4. Have People Annoyed You By Criticizing Your Drinking Or Drug Use?YesNo5. Have You Ever Felt Bad Or Guilty About Your Drinking Or Drug Use?YesNo6. Eye Opener: Have You Ever Had A Drink Or Used Drugs First Thing In The Morning To Steady Your Nerves Or Get Rid Of A Hangover?YesNoLIVING WILL1. Do You Have A Living Will?YesNoPlease Attached Your Living WillAccepted file types: jpg, png, pdf. HEART RISK ASSESSMENT1. Do You Suffer From Chest Pain?YesNo2. Do You Have Pain In Your Legs When Exercising?YesNo3. Do You Suffer From Shortness Of Breath?YesNo4. Do You Have Swelling In Your Legs, Feet, Or Hands?YesNo5. Do You Have Vision Disturbances?YesNo6. Do You See A Cardiologist?YesNo7. Did Your Father Or Mother Have Heart Disease?YesNoLUNG CANCER SCREENING1. Are You A Smoker?YesNo2. Have You Quit In The Last 15 Years?YesNo3. Did Or Do You Smoke One Or More Packs A Day?YesNo4. Have You Smoked For More Than 30 Years?YesNo5. Are You 55 To 77 Years Old?YesNo6. Are You Cancer-free (Never 6 Diagnosed With Lung Cancer)?YesNoNote: (If answers 1 or 2 are Yes and 3-5 are Yes or the total equals 30 pack years then candidate for CT Scan) It the patient is a never smoker or not age 55-77 -NA Do not drop codes. Patient Name:Patient Date of Birth: Date Format: MM slash DD slash YYYY Date Of Services Date Format: MM slash DD slash YYYY BMI (Body Mass Index)BPDepression (Patient Health Questionnaire-9) - (PHQ-9)Over The Last 2 Weeks How Often You Been Bothered By Any Of The Following Problems?1. Little Interest Or Pleasure In Doing ThingsNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 32. Feeling Down, Depressed Or HopelessNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 33. Trouble Falling Or Staying Asleep, Or Sleeping Too MuchNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 34. Feeling Tired Or Having Little EnergyNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 35. Poor Appetite Or OvereatingNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 36. Feeling Bad About Yourself Or That You Are A Failure Or Have Let Yourself Or Your Family DownNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 37. Trouble Concentrating On Things, Such As Reading The Newspaper Or Watching TelevisionNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 38. Moving Or Speaking So Slowly That Other People Could Have Noticed. Or The Opposite- Being So Fidgety Or Restless That You Have Been Moving Around A Lot More Than UsualNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 39. Thoughts That You Would Be Better Off Dead, Or Of Hurting YourselfNot At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 3Please Count and Enter Your Grand Total For Above Answers*10. If You Checked Off Any Problems, How Difficult Have These Problems Made It For You To Do Your Work, Take Care Of Things At Home, Or Get Along With Other People?Not Difficult At AllSomewhat DifficultVery DifficultExtremely Difficult Generalized Anxiety Disorder (GAD) ScaleOver The Last 2 Weeks, How Often Have You Been Bothered By The Following Problems?1. Feeling Nervous, Anxious Or On Edge.Not At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 22. Not Being Able To Stop Or Control Worrying.Not At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 33. Worrying Too Much About Different Things.Not At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 34. Trouble Relaxing.Not At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 35. Being So Restless That It's Hard To Sit Still.Not At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 36. Becoming Easily Annoyed Or Irritable.Not At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 37. Feeling Afraid As If Something Awful Might Happen.Not At All - 0Several Days - 1More Than Half The Days - 2Nearly Everyday - 3Please Count and Enter Your Grand Total For Above Answers* Please Mark And Answer The Questions Below To The Best Of Your Ability.1. Have You Had Any Falls Or Near Falls In Last 6 Months?YesNoNot SureFor Clinical Use Only: Fall Prevention_________ | Example Codes: 3288F2. Since Your Last Visit, Have Any Other Doctors Changed Your Medications?YesNoNot SureFor Clinical Use Only: Medication Rec.______ | Example Codes: 1111F3. Do You Have A Coronary Artery Disease (CAD) Heart Disease?YesNoNot SureFor Clinical Use Only: Physician Management ________3.1. Do You Take Aspirin Or Other Blood Thinners?YesNoNot Sure4. Do You Have Diabetes?YesNoNot SureFor Clinical Use Only: HBAIC ordered_______ | Eye exam ordered______ | Example Codes: 3044F 4.1. If Yes, Do You Know That The HBA1C Number Is?YesNoNot Sure4.2 If Yes, Have You Had A Diabetic Eye Exam In 2020?YesNoNot Sure5. Do You Believe Your Blood Pressure Is In Good Control?YesNoNot Sure6. Did You Have A Depression Screening In The Last 12 Months?YesNoNot SureFor Clinical Use Only: Depression Screening (PHQ) _______| Example Codes: G0444 7. (Females Only) Have You Had A Mammogram In The Last 2 Years?YesNoNot SureFor Clinical Use Only: Mammogram ordered____| Example Codes: 3014F 8. Have You Had A Colorectal Cancer Screening? This Includes A Stool Occult Blood, Colonoscopy In The Last 5 Years?YesNoNot SureFor Clinical Use Only: Colorectal CA screen____| Example Codes: 822749. Have You Received An Influenza Immunization Since October 2019?YesNoNot SureFor Clinical Use Only: Influenza Vac_____Denial Documented | Example Codes: Q2037, C00089.1. If No, Do You Wish To Receive One?YesNoNot Sure9.2 If You Do Not Wish To Receive One, Why?10. Have You Received A Pneumococcal Immunization After The Age 65?YesNoNot Sure10.1. If No, Would You Like A Pneumococcal Vaccination?YesNoNot SureFor Clinical Use Only: Pneumococcal vac______ | Example Codes: 90732, G000910.2 If You Do Not Wish To Receive A Pneumococcal, Why?11. Do You Smoke Cigarettes?YesNoFor Clinical Use Only: Tobacco Education________(smoking) | Example Codes: 9940611.1 If Yes, Would You Like To Quit?YesNo12. Do You Have An Advanced Care Plan/Directive?YesNoFor Clinical Use Only: Advance Care Planning ____ | Example Codes: 9949713. Are You Participating In The Chronic Care Management Program?YesNoFor Clinical Use Only: CCM Consented _____ | Example Codes: G050614. Do You Know Your BMI (Body Mass Index)?YesNoFor Clinical Use Only: Behavioral counseling for obesity_____ | Example Codes: G044714.1 If Yes, Is It Over 30?YesNo14.2 If Yes, Would You Like To Lose Weight?YesNo
